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Environmental Health Department <br />1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and daily products. <br />7. <br />8. <br />\SAN.dOAOUIN <br />------COUNTY------ <br />Grealfiess (/rov/s here'. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />Datefs):^^^^^^ <br />1868 E. Hazelton Avenue | Stockton, California 95206 | T 209 468-3420] F 209 464-0138 ( ww.sjcehd.corn <br />EHD 16.02 Page 7 of 11 TEMP EVENT APP <br />nvn/i 7 <br />• .r-D’J'A- <br />-<•-'■ t <br />■ ? <br /> Other (specify):_______________ ________———-------------------------------- <br />Electricity is provided for my booth's use: Yes No . . <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazaidous <br />foods during all times of booth operation: Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top Other (specify) <br />Note: Examples of potentially hazardous food Include: <br />the festival coordinator three (3) weeks prior to this event. <br />I.Name of Event: I (y! i JdarkfoT------ <br />The following is information about my organization/business: <br />Name of organization/business: j <br />MSI I Jdnrv/rir;la cA qgj5a <br />(20^1) Alternate: <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home: Yes ft No oPv <br />All food Is prepared on-site or is from approved commercial facilities: Yes No COWCX0C \ <br />Name of facility; Phone: {-------)----------------------------------- - <br />Address of facility: _________ ________________________—-------— ------------—-------------- ------- <br />I am providing a booth with the following; (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br /> A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing open food areas, It will also have a smooth and cleanable floor (conciete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public, <br />pother (specify): HT OCALYfl.(^Cd QkfoA].______ ___ _ <br />Note: The only operations not required to provide enclosed booths are those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />Approved bottled water. <br /> On-site hose bib that is connected to a potable water source.